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Management of cerebral palsy

Management of cerebral palsy. Definition.

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Management of cerebral palsy

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  1. Management of cerebral palsy

  2. Definition It is a group of disorder of the development of movement and posture, causing activity limitation, that are attributed to non progressive disturbance that occurred in the developing brain . The motor disorder of CP is often accompanied by disturbance of sensation , cognition communication perception and/or by a seizure disorder. (American academy of CP and development medicine)

  3. Diagnosis • Delayed motor milestones • Abnormal muscle tone • Hyperreflexia • Absence of regression or evidence of a more specific diagnosis

  4. 1.Intervention never should be delayed awaiting diagnosis or etiological assessment 2 families do the best when informed up front that cerebral palsy is the possibility

  5. Spasticity Vs dystonia Spasiticity: Spasticity- velocity dependent increase in tonic stretch reflex with exaggerated tendon jerks. Other motor phenomena of upper motor neuron: phasic stretch reflex (clonus and hyperreflexia), flexor and extensor spasms, co-contraction, dystonia Dystonia: involuntary muscles contraction that cause twisting ,repetitive movements and abnormal postures

  6. SPASTICITY • Present in most patient with CP (65 % ) • When reduced patients may : - perform integrated muscle movement - develop muscle strength - function at a higher level

  7. Modified Ashworth scale

  8. GMFCS • Ambulatory in all settings • Walks without aides but has limitations in community settings • Walks with aides • Mobility requires wheelchair or adult assist • Dependant for mobility

  9. GMFCS

  10. GMFCS

  11. Motor impairment 1.primary: muscle tone, balance, strength and selectivity problems that are directly related to damage in the CNS 2.Secondary:muscle contractures and deformity that develop over time in response to primary problem and musculoskeletal growth 3.tertiary:adaptive mechanism and coping responses that the child develops to adapt to the primary and secondary impairment.

  12. Goals of Spasticity: Management • Decrease spasticity • Improve functional ability and independence • Decrease pain associated with spasticity • Prevent or decrease incidence of contractures • Improve ambulation • Facilitate hygiene • Ease rehabilitation procedures • Save caregivers’ time • Near full participitation in society

  13. Treatment of spasticity and motor tone • Physical therapy • Orthotics • Assistive devices • Control of spasticity • Orthopedic surgery

  14. Timing of rehabilitative measures

  15. PHYSIOTHERAPY • Conventional PT : goal: bring child to erect posture, give independent mobility and prevent deformity works peripheral on muscles, tendons, and ligaments - Active exercises, - Passive ROM exercises - Passive stretching - Bracing

  16. PHYSIOTHERAPY • CNS modifications : applying external stimuli / effectiveness not proven e.g. - Neuro-developmental therapy - Sensory integration therapy - Patterning - Conductive education - Pressure point stimulation

  17. NDT(NeuroDevelopment therapy) • According to the Bobaths - the motor problems of cerebral palsy arise fundamentally from central nervous system (CNS) dysfunction which interferes with the development of normal postural control against gravity and impedes normal motor development. • Their goal was the establishment of normal motor development and function and/or the prevention of contractures and deformities.

  18. Effects of physiotherapy

  19. Maintenance Physical Therapy Goals : - balance and gait training - maximize voluntary muscle usage - prevent joint contractures -essential after orthopedic procedures and pubertal spurts.

  20. ORTHOTICS to hold extremity in stable and functional position. 1.Ankle foot orthosis :provide ankle stability, put foot I more functional position for gait & slow down contracture at ankles 2.Spinal orthosis: slow progression of scoliosis

  21. PHARMACOTHERAPY • Baclofen • Diazepam • Dantrolene Sodium • Tizanidine • Others

  22. MECHANISM OF ACTION

  23. Drug Baclofen: Diazepam: Dantrolene Sodium: Tizanidine: Site of action GABAb receptors in spinal cord Central nervous system Skeletal muscles beyond the myoneural junction Central acting (spinal and supraspinal) at alpha2 – adrenergic receptor sites

  24. BACLOFEN GABA agonist – inhibits release of excitatory neurotransmitter at level of spinal cord • Oral : mixed reports/ side effects/ not selective • Continuous intrathecal – implantable pump • Good results in releasing spasticity, and improving function • Complications of pump and catheter • Needs specialized centers

  25. Botulinum-A toxin Acts at myo-neural junctions Inhibits exocytosis of Acetylcholine • Inject selected muscles at multiple sites • Spasticity reduction may last up to 6 months • Reversible , painless , minimal side effects • Most patients still require lengthening for permanent correction • Role : - Facilitates physiotherapy and mobilization - Delays surgical management - Trial to determine effects of specific proposed surgical treatment

  26. SELECTIVE DORSAL RIHZOTOMY[SRD] Cut 30 – 50 % of abnormal dorsal rootlets L2 - S1 • Followed by intensive physiotherapy • Results encouraging • May cause hyperlordosis / hip subluxation • Best for :spastic diplegia, 4-8 yrs, no previous surgery, no contractures, no extra pyramidal signs • ? Not enough alone • Orthopedic procedures obtain similar results

  27. Orthopedic procedures Goal: ambulatory: straight spine, stable hip and horizontal pelvis and extended knee non ambulatory: facilitate sitting ,prevent pain and improve hygiene Depending on CNS maturation ,ambulation potential and rate of deformity development

  28. SOFT TISSUE PROCEDURES • Reduce muscle tone by lengthing the spastic muscle and reducing stretch reflex • Tenotomy • Tendon lengthening • Myotomy • Tendon transfers

  29. Orthopedic procedures 1)Contracture management: soft tissue procedures 2)Joint dislocations: osteotomies , arthrodeses 3)Bony deformities Timings: Soft tisses procedures-4-7 yrs Hand surgeries- 6-12yrs Bony procedures-aft 8 yrs

  30. Hip surveillance • Non ambulatory and who can walk fewer than 10 steps hip xray 30 month • Repeat every 6-12 month until 7 yrs • Spinal radiographs 5 and 10 yrs (dev med child neruo 2004)

  31. Oromotor Dysfunction • Especially common in persons with Extrapyramidal CP and Spastic quadriplegia • Language delay/Speech delays • Drooling • Dysphagia • Aspiration

  32. Gastrointestinal Dysmotility • Delayed gastric emptying • Gastroesophageal reflux • Pain • Chronic aspiration • Constipation These disorders are interrelated and compound one another.

  33. Associated problems • Mental Retardation • Communication Disorders • Neurobehavioral • Seizures • Vision Disorders • Hearing loss • Somatosensation (skin sensation, body awareness) • pain • Temperature instability • Nutrition • Drooling • Dentition problems • Gastroesophageal reflux • Dysphagia • Autonomic dysfunction

  34. THANKS!!!!!

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